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INTERESTING IMAGE
Year : 2021  |  Volume : 36  |  Issue : 3  |  Page : 343-346  

Fluorine-18 fluorodeoxyglucose positron emission tomography/ computed tomography in hodgkin's lymphoma: Diagnostic challenge during COVID vaccination


1 Department of Nuclear Medicine, Castle Hill Hospital, Cottingham, UK
2 Kuwait Cancer Control Center (KCCC), Cottingham, UK
3 Jack Brignall PET/CT Centre, Castle Hill Hospital, Cottingham, UK

Date of Submission05-Mar-2021
Date of Decision08-Mar-2021
Date of Acceptance11-Mar-2021
Date of Web Publication23-Sep-2021

Correspondence Address:
Dr. Sharjeel Usmani
Department of Nuclear Medicine, Kuwait Cancer Control Center (KCCC), PO Box 1488, 83001 Khaitan
UK
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijnm.ijnm_31_21

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   Abstract 


Benign metabolic uptake on fluorine-18 fluorodeoxyglucose positron emission tomography (18F-FDG PET) is not uncommonly seen after immunization. We report a case of 30-year-old man with Hodgkin's lymphoma who underwent two cycles of chemotherapy. Interim 18F-FDG PET/computed tomography demonstrated complete metabolic response of prior hypermetabolic bilateral supraclavicular and mediastinal lymph nodes. Although multiple new normal-sized hypermetabolic left axillary and subpectoral lymph nodes are noted, relevant history revealed COVID vaccine 7 days prior scan with mild FDG uptake at the left deltoid muscle. These new findings at the left axilla are likely related to recent vaccination. 18F-FDG PET uptake in the lymph nodes is not so uncommon after immunization; relevant history is very important especially in the phase of massive immunization to avoid false interpretation.

Keywords: Fluorine-18 fluorodeoxyglucose positron emission tomography, COVID-19, vaccination


How to cite this article:
Usmani S, Al-Ramadhan F, Al-Kandari F, Ahmed N. Fluorine-18 fluorodeoxyglucose positron emission tomography/ computed tomography in hodgkin's lymphoma: Diagnostic challenge during COVID vaccination. Indian J Nucl Med 2021;36:343-6

How to cite this URL:
Usmani S, Al-Ramadhan F, Al-Kandari F, Ahmed N. Fluorine-18 fluorodeoxyglucose positron emission tomography/ computed tomography in hodgkin's lymphoma: Diagnostic challenge during COVID vaccination. Indian J Nucl Med [serial online] 2021 [cited 2021 Dec 8];36:343-6. Available from: https://www.ijnm.in/text.asp?2021/36/3/343/326564



A 30-year-old male who has Hodgkin's lymphoma underwent two cycles of chemotherapy. Interim fluorine-18 fluorodeoxyglucose positron emission tomography (18F-FDG PET) post 7 days of first dose of Oxford COVID vaccine at the left deltoid muscle. Baseline 18F-FDG PET/computed tomography (18F-FDG PET/CT) shows hypermetabolic bilateral supraclavicular and mediastinal lymph nodes [Figure 1]. Interim 18F FDG PET images demonstrate complete metabolic resolution of prior supraclavicular and mediastinal lymph nodes [Figure 2]. There are multiple new normal-sized hypermetabolic left axillary and subpectoral lymph nodes that are noted along with mild increase tracer uptake in the left deltoid muscle. Subsequent ultrasonography of the axilla also revealed normal-looking lymph nodes. Keeping in view of history, these new findings at the left axilla are likely related to recent vaccination, a diagnosis of benign 18F-FDG uptake in the normal-sized axillary lymph nodes is made, and the follow-up is advised.
Figure 1: a) Baseline 18F-FDG PET MIP image and b-c) Transaxial PET/CT images show multiple hypermetabolic lymph nodes at bilateral supraclavicular and anterior mediastinal regions

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Figure 2: a) Interim 18F-FDG PET MIP image demonstrate complete metabolic response of prior hypermetabolic bilateral supraclavicular and mediastinal lymph nodes. Although multiple new hypermetabolic left axillary and subpectoral lymph nodes are noted. Non-contrast CT images show normal lymph nodes (c,d). Relevant history revealed COVID vaccine 7 days prior scan with mild FDG uptake at left deltoid muscle (b). These new findings at left axilla are likely related to recent vaccination

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18F-FDG PET is enormously used in diagnostic staging, restaging, and response evaluation in cancer patients; however, these findings are nonspecific for cancers and can also found in inflammatory and infectious conditions.[1],[2] 18F-FDG PET has shown a high overall accuracy in predicting treatment outcome in lymphoma, both during and after completion of treatment; despite that, a study carried out at an interim time point of therapy may not be able to discriminate between the presence of residual viable neoplastic tissue and a nonspecific inflammatory host response.[3] In literature, false-positive 18F-FDG uptake within the lymph nodes is reported after vaccination and has the highest probability if vaccination was administered <8 days before the scan.[4] Increased FDG activity in the ipsilateral deltoid muscle is a key finding for accurate interpretation of increased FDG activity in the axillary lymph nodes.[5],[6] However, Ayati et al.[7] also reported a case of generalized lymph node activation postinfluenza vaccination.

18F-FDG PET uptake in the lymph nodes by metabolically active tissue due to vaccine-related immune response has been encountered beforehand, and it is considered as a potential pitfall in images interpretation.[8],[9] Evidence in the literature has documented that the availability of clinical history increases the accuracy of radiologic image interpretation.[10] The role of clinical history is well established in 18F-FDG PET/CT study reporting more significantly in initial interim scans of lymphoma patients as results may alter the management plan considerably that the role was greatly emphasized by the presented case.

Acknowledgment

We would like to acknowledge Dr. Rashid Rasheed and Dr. Muneera Al Maraghy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Fletcher JW, Djulbegovic B, Soares HP, Siegel BA, Lowe VJ, Lyman GH, et al. Recommendations on the use of 18F-FDG PET in oncology. J Nucl Med 2008;49:480-508.  Back to cited text no. 1
    
2.
Stumpe KD, Dazzi H, Schaffner A, von Schulthess GK. Infection imaging using whole-body FDG-PET. Eur J Nucl Med 2000;27:822-32.  Back to cited text no. 2
    
3.
Gallamini A, Zwarthoed C. Interim FDG-PET imaging in lymphoma. Semin Nucl Med 2018;48:17-27.  Back to cited text no. 3
    
4.
Burger IA, Husmann L, Hany TF, Schmid DT, Schaefer NG. Incidence and intensity of F-18 FDG uptake after vaccination with H1N1 vaccine. Clin Nucl Med 2011;36:848-53.  Back to cited text no. 4
    
5.
Coates EE, Costner PJ, Nason MC, Herrin DM, Conant S, Herscovitch P, et al. Lymph node activation by PET/CT following vaccination with licensed vaccines for human papillomaviruses. Clin Nucl Med 2017;42:329-34.  Back to cited text no. 5
    
6.
Panagiotidis E, Exarhos D, Housianakou I, Bournazos A, Datseris I. FDG uptake in axillary lymph nodes after vaccination against pandemic (H1N1). Eur Radiol 2010;20:1251-3.  Back to cited text no. 6
    
7.
Ayati N, Jesudason S, Berlangieri SU, Scott AM. Generalized lymph node activation after influenza vaccination on 18F FDG-PET/CT imaging, an important pitfall in PET interpretation. Asia Ocean J Nucl Med Biol 2017;5:148-50.  Back to cited text no. 7
    
8.
Shirone N, Shinkai T, Yamane T, Uto F, Yoshimura H, Tamai H, et al. Axillary lymph node accumulation on FDG-PET/CT after influenza vaccination. Ann Nucl Med 2012;26:248-52.  Back to cited text no. 8
    
9.
Williams G, Joyce RM, Parker JA. False-positive axillary lymph node on FDG-PET/CT scan resulting from immunization. Clin Nucl Med 2006;31:731-2.  Back to cited text no. 9
    
10.
Niederkohr RD, Greenspan BS, Prior JO, Schöder H, Seltzer MA, Zukotynski KA, et al. Reporting guidance for oncologic 18F-FDG PET/CT imaging. J Nucl Med 2013;54:756-61.  Back to cited text no. 10
    


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